Influenza With and Without Fever: Clinical Predictors and Impact on Outcomes in Patients Requiring Hospitalization.

BACKGROUND: The Infectious Diseases Society of America influenza guidelines no longer require fever as part of their influenza case definition in patients requiring hospitalization. However, the impact of fever or lack of fever on clinical decision-making and patient outcomes has not been studied. METHODS: We conducted a retrospective review of adult patients admitted to our tertiary health service between April 2016 and June 2019 with laboratory-confirmed influenza, with and without fever (≥37.8ºC). Patient demographics, presenting features, and outcomes were analyzed using Pearson's chi-square test, the Wilcoxon rank-sum test, and logistic regression. RESULTS: Of 578 influenza inpatients, 219 (37.9%) had no fever at presentation. Fever was less likely in individuals with a nonrespiratory syndrome (adjusted odds ratio [aOR], 0.44; 95% CI, 0.26-0.77), symptoms for ≥3 days (aOR, 0.53; 95% CI, 0.36-0.78), influenza B infection (aOR, 0.45; 95% CI, 0.29-0.70), chronic lung disease (aOR, 0.55; 95% CI, 0.37-0.81), age ≥65 (aOR, 0.36; 95% CI, 0.23-0.54), and female sex (aOR, 0.69; 95% CI, 0.48-0.99). Patients without fever had lower rates of testing for influenza in the emergency department (64.8% vs 77.2%; P = .002) and longer inpatient stays (median, 2.4 vs 1.9 days; P = .015). These patients were less likely to receive antiviral treatment (55.7% vs 65.6%; P = .024) and more likely die in the hospital (3.2% vs 0.6%; P = .031), and these differences persisted after adjustment for potential confounders. CONCLUSIONS: Absence of fever in influenza is associated with delayed diagnosis, longer length of stay, and higher mortality.

Evaluation of a multifaceted intervention on documentation of vital signs at triage: a before-and-after study.

BACKGROUND: Triage systems provide a centralised safety mechanism where all patients are assessed for clinical urgency at point of entry to the ED. OBJECTIVE: The present study aims to evaluate the effect of a multifaceted intervention on triage documentation rates and guideline adherence. METHODS: A before-and-after design was used. The intervention involved restructuring the computerised interface, regular audit and feedback and education sessions. The setting was one adult tertiary referral hospital and major trauma centre located in Melbourne, Australia. Participants were triage nurses. Data were collected at five time points for a consecutive sample of one month of presentations. RESULTS: Over a 15 month period, we sampled 35.8% (24,862/69,395) episodes of triage performed by 122 nurses. Documentation rates for all vital signs progressively increased from baseline. There were significant increases in the proportion of episodes of triage where any vital sign was documented (32.2% vs 82.6%), and where pair and triplet combinations of vital signs were recorded in the triage field (heart rate and respiratory rate: 17.9% vs 64.6%; heart rate, respiratory rate and temperature: 7.0% vs 30.4%). No significant change in guideline adherence was observed after the intervention. CONCLUSION: Progressive sustained improvements in vital sign documentation were observed over the study period; however, no such increases were noted in guideline adherence. To facilitate evaluation of guideline adherence, we recommend specific vital sign parameters be included in the Australasian Triage Scale Guideline for all levels of urgency.